Oklahoma Bans Forced MOC, Becomes the First “Right to Care” State

On Tuesday, April 12, Oklahoma Governor Mary Fallin signed SB 1148 into law and freed every Oklahoma physician from the ABMS MOC. I get chills thinking about how awesome this is and what an incredible model it is for all of us. It’s just beautiful.

“Nothing in the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment or admitting privileges at a hospital in this state. For the purposes of this subsection, “Maintenance of Certification (MOC)” shall mean a continuing education program measuring core competencies in the practice of medicine and surgery and approved by a nationally recognized accrediting organization.”

Wow. Even more jaw-dropping is that this landmark legislation passed through the Oklahoma house and senate unanimously. In a time when gridlock is a given, MOC is something that unites us all. The funny thing is, this law shouldn’t be revolutionary. It simply legislates exactly what ABMS says about board certification: that it is voluntary. ABMS has long claimed “board certification is a voluntary process, and one that is very different from medical licensure.” But for those of us on the ground, it’s very clear that it is NOT voluntary. We can quickly lose our jobs, our hospital privilidges, and our insurance participation if we choose not to participate in any portion of MOC.

Oklahoma simply called their bluff, and now all physicians in Oklahoma are free to choose if they want to participate in ABMS MOC, if they want to certify through alternative boards like NBPAS, or if they just want to be done with the whole lot. They are free.

I can’t help but see parallels between our fight as physicians against forced board certification and what my friends in the union have faced with forced union membership. The issue of free choice is similar, and the intimidating political power of those opposing choice is similar.

In 2012, when Michigan was in the process of becoming the 24th Right to Work state, I was surprised to learn that many of those leading the Right to Work fight in Michigan were unionworkers, who actually liked the idea of the union. The problem was, the union had lost their way, and had no incentive to represent the workers when membership was forced. These union workers didn’t want to destroy the unions, they actually wanted a better union, one that responded to the workers. But until they had a choice, the union had no incentive to change. The issue was about individual choice. It was about the right to choose to join or not join the union, without fear of losing a job.

This is exactly what we are talking about with MOC legislation. Instead of “Right to Work”, this is “Right to Care”. Our complaint isn’t against ABMS and their subspecialty boards. They can do what they want and require what they want of their diplomates. We cannot change that. Our complaint is with being forced to participate in an ever-changing process they claim is voluntary. We should be free to care for our patients, free to pursue novel clinical research, and free to choose our own continuing education. If ABMS and the subspecialty boards are providing a quality educational product at a good value, doctors should be free to participate. If doctors do not see educational value in ABMS MOC products, they should be free to pursue education elsewhere without fear of losing their jobs or ability to practice.

This freedom to choose is something we gain at the state level, through legislation supported by the state medical societies. There are 19 state medical societies that have passed resolutions opposing compulsory MOC, and now the state societies are turning resolutions into state legislation. Missouri was the first brave state, with representative Keith Frederick DO initially introducing HB 671 and HB 683, currently active as HB 2304, the current bill still awaiting a hearing. Michigan State Medical Society has launched an innovative “Right 2 Care” education campaign in support of 4 bills: SB 608 and SB 609, HB 5090 and HB 5090. Among the list of sponsors of this Michigan legislation are representatives Ed Canfield DO and John Bizon MD. These bills are also waiting for a committee hearing.

Last week finally brought the breakthrough we’ve been waiting for. On April 8, Kentucky governor Matt Bevin signed SB17 into law. This bill, sponsored by senator Ralph Alverado MD was the first state “MOL” legislation to be passed and signed, preempting any attempt to require board certification for a state medical license. And now Oklahoma’s SB1148, sponsored by senator Brian Crain and representative Mike Ritze DO, is the nation’s first full Right to Care law preventing MOC from being required for a license, hospital privileges, insurance reimbursement, or employment. Cracks in the ABMS facade have been steadily growing, and Oklahoma just blasted through with a wrecking ball. The momentum is definitely on our side.

In case you missed it, there’s one thing all these states have in common: physician legislators. Keith Frederick DO (@keithjfrederick), Ed Canfield DO, John Bizon MD (@DrJohnBizon), Ralph Alverado MD(@Alvarado4Senate) , and Mike Ritze DO are to be commended, donated to, followed, tweeted and cheered. They’ve gone into the thick of it, and unlike so many physicians who become politicians, they haven’t forgotten us.

Missouri, Michigan, Kentucky, and Oklahoma have paved the way for other states to follow. They’ve already hashed out the legislative language to make it easy in other states. Oklahoma has shown the bipartisan appeal of this legislation, and that we can prevail over the powerful insurance lobby. hospital lobby and ABMS. Every doc should call their state medical societies and local lawmakers today while this news is fresh, and ask them to take up similar legislation in every state.

As one physician on Sermo commented…”One small step for Oklahoma, one giant leap for physicians.” Let’s set our sites on the moon, docs.

About Meg Edison MD

Comments

This OK law is an expansion of the Code of Federal Regulations which already bans requiring participation in a specialty organization as the sole criteria for denying hospital privileges. Adding state licensure and insurance panels completes the trifecta. One down, 49 states to go.

And here is the CMS “iterpretive guidance” for this rule:
Interpretive Guidelines §482.12(a)(7): In making a judgment on medical staff membership, a hospital may not rely solely on the fact that a MD/DO is, or is not, board-certified. This does not mean that a hospital is prohibited from requiring board certification when considering a MD/DO for medical staff membership, but only that such certification must not be the only factor that the hospital considers. In addition to matters of board certification, a hospital must also consider other criteria such as training, character, competence and judgment. After analysis of all of the criteria, if all criteria are met except for board certification, the hospital has the discretion to decide not to select that individual to the medical https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf

This is a good thing, but this legislation is in no way like so-called “right to work” legislation. Right to work legislation is about disempowering workers through weakening collective bargaining; this is exactly the opposite. Never thought that I would say this, but good work, Oklahoma.

I think you may have made my point. There are narratives both union workers and doctors have to break through to get the truth out there and regain our free choice. For union workers, they get called “free loaders”, when in fact federal law forces them to bargain with the union even when they are no longer members. Doctors get accused of trying to shirk accountability, when in fact these specialty boards have no jurisdiction to protect the public from bad doctors. In the end, it’s all about choice. No one should be forced to give money to these outside unaccountable organizations upon condition of employment. I’m actually hoping the boards listen and reverse course to save themselves and their reputations. I was really proud of my board certification!

We are fighting the Interstate Medical Licensure Compact which links by law doctors to the ABMS. What a relief to know that Oklahoma is a place where doctors can go if the fight is continuous!
Next to make sure the FSMB’s Maintenanceof Licensure doesn’t get linked to licensure. They are “studying feasibility ” as more states ratify their Compact bill.
Any Rhode Island docs join our movement at http://www.riphysicians.org

You are absolutely correct. Does the medical society in RI have a policy resolution against MOC and the compact? A compact may be a good idea, but the FSMB Compact is a terrible idea as it requires ABMS certification to get the license. I don’t know how that’s legal, to favor one certification company.

Unfortunately, the RI Medical Society was promoting the Compact initially quietly and now more loudly as the opposition mounts. The executive director is a PhD in German Literature and the “grandfathered” MDs promoting it seem to not care who gets caught in the crossfire. Interestingly, the FSMB is offering bill promotion “scholarships” up to $60,000. I am sure that it is only a coincidence that the RI medical society is willing to give the FSMB a blank check from the RI treasury so that 40 docs (the Pres estimated) could participate in such a program with no guarantee of faster than our current process.
Hmm

Where in the statute does Oklahoma actually ban MOC? I skimmed through the bill text and did not find anything that prevented hospitals from having their own employment requirements which may or may not include MOC. All I can see is that MOC is not part of the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act which is not the same as an outright ban. Thanks

Ferdinand, time will tell if this bill needs refining, but the intent of the law is to prevent MOC from being required by insurers and hospitals, not just for a license. In speaking with the OMSA legislative director, and other colleagues in OK involved in this, the legal team creating this bill wrote it in such a way as to impact all aspects of freedom to practice without MOC, not just licensure. I haven’t read their whole Medical Practice Act that this is amending, but per their lawyers, this does provide protection beyond just licensure. Using this exact language in every state might not work, as every state medical practice act is different.

I disagree with your assessment, while I understand that certification may be a burden, it is necessary in order to assess competency. Is in it in the best interest of our patients to demonstrate our capability, the system is not perfect but the solution is not eliminate it. This is not the same as “right to work”, our situation is very different.

@hectorquintanella when you say certification may be a burden I assume by “certification” you mean MOC. MOC is not “necessary in order to assess competency ” as you state, far from it. Board certification plus continued CME activity and actively practicing medicine are better insurance of competency in my book then using some pay for play MOC modules that are just busy work and a big waste of time and money for clinicians. I praise Oklahoma for being the first state to make MOC unnecessary for being able to practice and have privileges etc, hopefully all states will follow and we will able to see our patients and go to conferences and symposiums and do self-study and not be beholden to the board-industrial complex.

I agree, perhaps Hector is confusing initial certification with MOC. The only doctors who support MOC are either grandfathered, on the boards, or haven’t done MOC yet. You’re correct, MOC has never ever been shown to demonstrate competency. It’s only been shown to pad the wallets of the multi-million dollar testing and certification corporations. If anything, it harms physicians by limiting our options for continuing education and encouraging poor research.

I’m one of those “grandfathered doctors”, and I can assure you that I’m dead-set against the MOC. I view it for what it is – a major burden for MDs/DOs and a great money-making scheme for the various ABMS Boards. It’s akin to the various department stores “extended warranty” programs, which basically sell you the same appliance twice. The ABMS has gone one step further, and turned the permanent certification into a perpetual source of income! If others follow in the ABMS’ footsteps, we will soon find MOD (Maintenance of Diploma) by Med Schools and one can reduce this to the absurd, and go all the way to a MOBC – Maintenance of Birth Certificate (Hey, why not…it’s another source of income, which is what this whole thing’s about in the first place!)

Now, on a more serious note – would it be possible to create a draft of this OK Law such that each of us could submit it to our favorite legislators and ask that a similar law be passed in each of the other 49 States?

I think it’s very reasonable for patients to expect their doctors are continuing to learn and expand their skills. Our job is NOT the same as construction, or dock workers or trucking. The knowledge base required to be “good” is ever changing and is invisible to patients. Having a professional board hold its practioners accountable is reasonable and maintains a public trust. We are a highly respected profession and we should continue to hold ourselves to a higher standard to we can expect that respect (and subsequent compensation) to decline. MOC isn’t perfect but the principle of it is reasonable and is part of the reason I love to be a doctor: I want to be held to a high standard. Until patients can obtain detailed data about the quality of a physician (our outcomes on key measures, determined by our board) they can at least be assured we are participating in ongoing education.

Lastly, this doesn’t mention how insurance providers would view physicians who loose their specialty boarding by non-compliance with the MOC. My guess is state govt might pay but private insurance may not. Lastly, such an approach would tether the physician to the state. Should you need to move, good luck.

Double lastly, maybe physicians should be asking the ABMS to show some data that the elements of MOC make physicians better. That seems a reasonable request for our leadership. Dropping the bar is not the answer and moves in the opposite direction of what society wants from us.

We have asked these questions and they don’t respond with anything but diversion and fear tactics. In a debate with Tierstein vs Baron and Nora they were so embarrassed by their inability to answer questions meaningfully, they wouldn’t release video debate publicly.

Hector Quintanilla taking a test where most of us study a few months before and then regurgitate facts does not measure competency. ABIM and certification in fact historically were always voluntary, even taking the Boards for the first time. Textbooks get outdated as do the materials on testing. In fact many of the questions asked are not clinically relevant to the practice. As physicians we are constantly reviewing articles and are inundated with updates by, just to name a few medscape, and other online sites. We also have access to immediately available online resources that can be used at a moments notice. So no, taking a test and paying thousands of dollars every ten years does not ensure any competency. I have rectified twice already and going to work the next day after my recert did not in anyway better my practice.

In MO, I sponsored the bill that prohibits our Board of Healing Arts from requiring MOC or participating in any particular insurance plan or using Meaningless Use EHR as a condition of licensure, and that bill is now in the Governor’s desk. I am currently having a bill drafted in MO using the OK language to extend this prohibition to insurance reimbursement and hospital privileges. We have over 50% burnout among physicians and we lose more than 400 doc’s a year to suicide. Med students and residents have high rates of depression and suicude. These abusive requirements, and others (i.e. PQRS, MACRA, MIPS, APS), in addition to EHR’s with terrible user interface, increasing obstructions to care by insurance companies, the badly flawed legal system, are all taking their toll on us doctors. To be able to provide care for our patients we must fight back. The bill that Oklahoma passed UNANIMOUSLY must be a priority in every state. I intend to lead the way in Missouri.

BTW, we should also prohibit con compete clauses in our contracts starting with 501C3 charitable hospitals, and we should clear the way for Direct Primary Care (done in MO last year) and we should allow new docs who don’t match to work in Collaborative Practice with a licensed doc (we created Assistant Physician in MO 2 yrs ago- rules and regs almost done). My cell is (573)201-8914 – call me with any comments or questions. I am a DO orthopedic surgeon and member of the Missouri House.

I’d like to see the exams made more strenous and varied, and the prep courses themselves optional (to avoid the cram/regurgitate approach). With the technological tools we now have (virtual reality, sophisticated physical models and AI are three which come to mind). The bottom line is that it isn’t as important to take classes, more important to thoroughly demonstrate mastery of a specialty.

great work!!!! this is really exciting news!! thanks to all physicians who stood up for the rest of us. Meg, please educate us on how we should approach our own state legislators. do we have to sign petition papers too?

Probably deserves a whole new post, right? I think the first step is getting your state medical society behind you. It’s possible to find some friendly lawmakers who will push this without the support of the medical society, but a needless uphill battle. The list of state societies is here: http://rebel.md/state-medical-society-resolutions-against-moc/

If your state is on that list, call up the legislative director of your medical society and ask what the plan is to get the resolution into legislation, and offer up Michigan and OK as starting points. Michigan is taking on all BC, OK only took on MOC, there are advantages to both. Also, ask them what lawmakers in your state are doctors. It’s easier to ask them than look up the bios of all your legislators! Call those docs up and talk to them about MOC legislation and if they’d be willing to introduce it. This would be a huge political win for them, garnering the support of nearly every doc in their state. A no brainer.

If you state isn’t on that list, gotta get involved in your state medical society and get a resolution. It takes time, but slow and steady gets this done.

This is great news. Hopefully this will apply to recertification as well and other states will follow suit.
These corporations like ABMS and ABIM have become giants and need to be investigated how they have influenced/bribed the academic institutions, hospitals, state boards and insurance companies to deny licensing /previliges and payments to physicians though they were never mandatory. The testing is very irrelevant to our practices and does not hold my hand ground when looked at practically and especially legally. ABIM has taken a time delaying stance hoping that this storm will pass but their hedgemony should be destroyed once and for all to stop this Madison racket.

Dr. Edison writes (emphasis added): “THEY can do what they want and require what they want of their diplomates. WE cannot change that.”

It wasn’t always a “they” and “we” situation between specialty boards and physicians. My understanding is that the certifying boards were originally created by medical specialty societies, simply as a means of indicating that a particular physician had in the eyes of his/her peers demonstrated particular proficiency in his/her area of expertise.

Somewhere along the way, the ownership/governance of the boards began to develop an identity apart from the physicians they were certifying; they have become part of what I think of the administrative-managerial complex. And with that came mission creep: board certification as the basis for licensure, hospital privileges, etc.

Ultimately, the only way to undo this process is for physicians to re-assert their governance of the certifying boards.

I think we have to write a letter asking Dr. David G Nichols ( ABP CEO) to disclose why he has such high salary (income). I am not sure, but I read he makes more than a million per year. Why so high number??

Now in practice in OK for 35 years, I can say that our state medical societies (MD and DO) and the component county medical societies have continually sought ways to improve public and private delivery of quality healthcare. We have not always been successful but this initiative was. Oklahoma physicians still will need board certification in most hospitals for privileges but the onerous, often capricious and expensive MOC is kaput! And I understand specialty societies and related boards are beginning to recognize this. Oklahoma physicians were also proponents of the legislature years ago to divert the $ millions from the cigarette industry settlement into an account which is only used to address and educate the scourge of tobacco use. It cannot be used for any other state need. The relatively poor health of many of our citizens is not primarily lack of resources, lack of access to good healthcare or even education but is because people still refuse to make good choices in their lives. No legislation can combat ignorance and willful self destruction!
P.S, responding to several prior comments, do move to OK! It’s a great place to practice with almost any topography from which to choose, from forested “mountains” to huge lakes, green countysides and pastured expanses! And a passion to keep “Big Brother” at bay!

Meg: I’m working with the Oregon Medical Assn., and would love it if you could provide a template for both your medical society resolution, and MI state law proposal ? Thanks, Paul
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